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(BQ) Part 1 book Harrison''s pulmonary and critical care medicine presents the following contents: Diagnosis of respiratory disorders, diseases of the respiratory system, general approach to the critically ill patient.
2nd Edition HARRISON’S TM Pulmonary and Critical Care Medicine Derived from Harrison’s Principles of Internal Medicine, 18th Edition Editors Dan L Longo, md Professor of Medicine, Harvard Medical School; Senior Physician, Brigham and Women’s Hospital; Deputy Editor, New England Journal of Medicine, Boston, Massachusetts Dennis L Kasper, md William Ellery Channing Professor of Medicine, Professor of Microbiology and Molecular Genetics, Harvard Medical School; Director, Channing Laboratory, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts J Larry Jameson, md, phd Robert G Dunlop Professor of Medicine; Dean, University of Pennsylvania School of Medicine; Executive Vice-President of the University of Pennsylvania for the Health System, Philadelphia, Pennsylvania Anthony S Fauci, md Chief, Laboratory of Immunoregulation; Director, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland Stephen L Hauser, md Robert A Fishman Distinguished Professor and Chairman, Department of Neurology, University of California, San Francisco, San Francisco, California Joseph Loscalzo, md, PhD Hersey Professor of the Theory and Practice of Medicine, Harvard Medical School; Chairman, Department of Medicine; Physician-inChief, Brigham and Women’s Hospital, Boston, Massachusetts 2nd Edition HARRISON’S TM Pulmonary and Critical Care Medicine Editor Joseph Loscalzo, Md, Phd Hersey Professor of the Theory and Practice of Medicine, Harvard Medical School; Chairman, Department of Medicine; Physician-in-Chief, Brigham and Women’s Hospital, Boston, Massachusetts New York Chicago San Francisco Lisbon London Madrid Mexico City Milan New Delhi San Juan Seoul Singapore Sydney Toronto Copyright © 2013 by McGraw-Hill Education, LLC All rights reserved Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher ISBN: 978-0-07-181495-9 MHID: 0-07-181495-7 The material in this eBook also appears in the print version of this title: ISBN: 978-0-07-181494-2, MHID: 0-07-181494-9 All trademarks are trademarks of their respective owners Rather than put a trademark symbol after every occurrence of a trademarked name, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the trademark Where such designations appear in this book, they have been printed with initial caps McGraw-Hill Education eBooks are available at special quantity discounts to use as premiums and sales promotions, or for use in corporate training programs To contact a representative please e-mail us at bulksales@mcgraw-hill.com Dr Fauci’s work as an editor and author was performed outside the scope of his employment as a U.S government employee This work represents his personal and professional views and not necessarily those of the U.S government This book was set in Bembo by Cenveo® Publisher Services The editors were James F Shanahan and Kim J Davis The production supervisor was Catherine H Saggese Project management was provided by Tania Andrabi, Cenveo Publisher Services The cover design was by Thomas DePierro Cover illustration, x-ray of the lungs, from BSIP/Science Source TERMS OF USE This is a copyrighted work and McGraw-Hill Education, LLC and its licensors reserve all rights in and to the work Use of this work is subject to these terms Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the work, you may not decompile, disassemble, reverse engineer, reproduce, modify, create derivative works based upon, transmit, distribute, disseminate, sell, publish or sublicense the work or any part of it without McGraw-Hill Education’s prior consent You may use the work for your own noncommercial and personal use; any other use of the work is strictly prohibited Your right to use the work may be terminated if you fail to comply with these terms THE WORK IS PROVIDED “AS IS.” McGRAW-HILL EDUCATION AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE McGraw-Hill Education and its licensors not warrant or guarantee that the functions contained in the work will meet your requirements or that its operation will be uninterrupted or error free Neither McGraw-Hill Education nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom McGraw-Hill Education has no responsibility for the content of any information accessed through the work Under no circumstances shall McGraw-Hill Education and/or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise Contents Contributors vii 14 Common Viral Respiratory Infections 157 Raphael Dolin Preface xi 15 Pneuzmocystis Infections 168 A George Smulian, Peter D Walzer SECTION I Diagnosis of Respiratory Disorders 16 Bronchiectasis and Lung Abscess 172 Rebecca M Baron, John G Bartlett Approach to the Patient with Disease of the Respiratory System Patricia Kritek, Augustine Choi 17 Cystic Fibrosis 179 Richard C Boucher Dyspnea Richard M Schwartzstein 18 Chronic Obstructive Pulmonary Disease 185 John J Reilly, Jr., Edwin K Silverman, Steven D Shapiro Cough and Hemoptysis 14 Patricia Kritek, Christopher Fanta Hypoxia and Cyanosis 21 Joseph Loscalzo 19 Interstitial Lung Diseases 197 Talmadge E King, Jr Disturbances of Respiratory Function 26 Edward T Naureckas, Julian Solway 20 Deep Venous Thrombosis and Pulmonary Thromboembolism 211 Samuel Z Goldhaber Diagnostic Procedures in Respiratory Disease 36 Anne L Fuhlbrigge, Augustine M K Choi 21 Disorders of the Pleura and Mediastinum 221 Richard W Light Atlas of Chest Imaging 45 Patricia Kritek, John J Reilly, Jr 22 Disorders of Ventilation 227 John F McConville, Julian Solway SECTION II 23 Sleep Apnea 232 Neil J Douglas Diseases of the respiratory system 24 Lung Transplantation 237 Elbert P Trulock Asthma 66 Peter J Barnes Hypersensitivity Pneumonitis and Pulmonary Infiltrates With Eosinophilia 85 Alicia K Gerke, Gary W Hunninghake Section III General Approach to the Critically Ill Patient 10 Occupational and Environmental Lung Disease 93 John R Balmes, Frank E Speizer 25 Approach to the Patient with Critical Illness 244 John P Kress, Jesse B Hall 11 Pneumonia 105 Lionel A Mandell, Richard Wunderink 26 Mechanical Ventilatory Support 256 Bartolome R Celli 12 Tuberculosis 121 Mario C Raviglione, Richard J O’Brien 27 Approach to the Patient with Shock 263 Ronald V Maier 13 Influenza 147 Raphael Dolin v Contents vi Section IV Common Critical Illnesses and Syndromes 28 Severe Sepsis and Septic Shock 276 Robert S Munford 29 Acute Respiratory Distress Syndrome 288 Bruce D Levy, Augustine M K Choi 37 Fluid and Electrolyte Disturbances 375 David B Mount 38 Acidosis and Alkalosis 400 Thomas D DuBose, Jr 39 Coagulation Disorders 414 Valder R Arruda, Katherine A High 30 Cardiogenic Shock and Pulmonary Edema 295 Judith S Hochman, David H Ingbar 40 Treatment and Prophylaxis of Bacterial Infections 427 Gordon L Archer, Ronald E Polk 31 Cardiovascular Collapse, Cardiac Arrest, and Sudden Cardiac Death 303 Robert J Myerburg, Agustin Castellanos 41 Antiviral Chemotherapy, Excluding Antiretroviral Drugs 450 Lindsey R Baden, Raphael Dolin 32 Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction 313 Christopher P Cannon, Eugene Braunwald 42 Diagnosis and Treatment of Fungal Infections 465 John E Edwards, Jr 33 ST-Segment Elevation Myocardial Infarction 321 Elliott M Antman, Joseph Loscalzo 34 Coma 341 Allan H Ropper 35 Neurologic Critical Care, Including HypoxicIschemic Encephalopathy, and Subarachnoid Hemorrhage 351 J Claude Hemphill, III, Wade S Smith, Daryl R Gress Section V Disorders Complicating Critical Illnesses and their Management 36 Dialysis in the Treatment of Renal Failure 368 Kathleen D Liu, Glenn M Chertow 43 Oncologic Emergencies 469 Rasim Gucalp, Janice Dutcher Appendix Laboratory Values of Clinical Importance 485 Alexander Kratz, Michael A Pesce, Robert C Basner, Andrew J Einstein Review and Self-Assessment 511 Charles Wiener, Cynthia D Brown, Anna R Hemnes Index 573 vii Contributors Numbers in brackets refer to the chapter(s) written or co-written by the contributor Agustin Castellanos, MD Professor of Medicine, and Director, Clinical Electrophysiology, Division of Cardiology, University of Miami Miller School of Medicine, Miami, Florida [31] Elliott M Antman, MD Professor of Medicine, Harvard Medical School; Brigham and Women’s Hospital; Boston, Massachusetts [33] Gordon L Archer, MD Professor of Medicine and Microbiology/Immunology; Senior Associate Dean for Research and Research Training, Virginia Commonwealth University School of Medicine, Richmond, Virginia [40] Bartolome R Celli, MD Lecturer on Medicine, Harvard Medical School; Staff Physician, Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, Massachusetts [26] Valder R Arruda, MD, PhD Associate Professor of Pediatrics, University of Pennsylvania School of Medicine; Division of Hematology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania [39] Glenn M Chertow, MD, MPH Norman S Coplon/Satellite Healthcare Professor of Medicine; Chief, Division of Nephrology, Stanford University School of Medicine, Palo Alto, California [36] Lindsey R Baden, MD Associate Professor of Medicine, Harvard Medical School; DanaFarber Cancer Institute, Brigham and Women’s Hospital, Boston, Massachusetts [41] Augustine M K Choi, MD Parker B Francis Professor of Medicine, Harvard Medical School; Chief, Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, Massachusetts [1, 6, 29] John R Balmes, MD Professor of Medicine, San Francisco General Hospital, San Francisco, California [10] Raphael Dolin, MD Maxwell Finland Professor of Medicine (Microbiology and Molecular Genetics), Harvard Medical School; Beth Israel Deaconess Medical Center; Brigham and Women’s Hospital, Boston, Massachusetts [13, 14, 41] Peter J Barnes, DM, DSc, FMedSci, FRS Head of Respiratory Medicine, Imperial College, London, United Kingdom [8] Neil J Douglas, MD, MB ChB, DSc, Hon MD, FRCPE Professor of Respiratory and Sleep Medicine, University of Edinburgh, Edinburgh, Scotland, United Kingdom [23] Rebecca M Baron, MD Assistant Professor, Harvard Medical School; Associate Physician, Department of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, Massachusetts [16] Thomas D DuBose, Jr., MD, MACP Tinsley R Harrison Professor and Chair, Internal Medicine; Professor of Physiology and Pharmacology, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina [38] John G Bartlett, MD Professor of Medicine and Chief, Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland [16] Janice Dutcher, MD Department of Oncology, New York Medical College, Montefiore, Bronx, New York [43] Robert C Basner, MD Professor of Clinical Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, New York [Appendix] John E Edwards, Jr, MD Chief, Division of Infectious Diseases, Harbor/University of California, Los Angeles (UCLA) Medical Center, Torrance, California; Professor of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California [42] Richard C Boucher, MD Kenan Professor of Medicine, Pulmonary and Critical Care Medicine; Director, Cystic Fibrosis/Pulmonary Reseach and Treatment Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina [17] Eugene Braunwald, MD, MA (Hon), ScD (Hon) FRCP Distinguished Hersey Professor of Medicine, Harvard Medical School; Founding Chairman, TIMI Study Group, Brigham and Women’s Hospital, Boston, Massachusetts [32] Andrew J Einstein, MD, PhD Assistant Professor of Clinical Medicine, Columbia University College of Physicians and Surgeons; Department of Medicine, Division of Cardiology, Department of Radiology, Columbia University Medical Center and New York-Presbyterian Hospital, New York, New York [Appendix] Cynthia D Brown Assistant Professor of Medicine, Division of Pulmonary and Critical Care Medicine, University of Virginia, Charlottesville, Virginia [Review and Self-Assessment] Christopher Fanta, MD Associate Professor of Medicine, Harvard Medical School; Member, Pulmonary and Critical Care Division, Brigham and Women’s Hospital, Boston, Massachusetts [3] Christopher P Cannon, MD Associate Professor of Medicine, Harvard Medical School; Senior Investigator, TIMI Study Group, Brigham and Women’s Hospital, Boston, Massachusetts [32] Anne L Fuhlbrigge, MD, MS Assistant Professor, Harvard Medical School; Pulmonary and Critical Care Division, Brigham and Women’s Hospital, Boston, Massachusetts [6] vii viii Contributors Alicia K Gerke, MD Associate, Division of Pulmonary and Critical Care Medicine, University of Iowa, Iowa City, Iowa [9] Patricia Kritek, MD, EdM Associate Professor, Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington [1, 3, 7] Samuel Z Goldhaber, MD Professor of Medicine, Harvard Medical School; Director, Venous Thromboembolism Research Group, Cardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts [20] Bruce D Levy, MD Associate Professor of Medicine, Harvard Medical School; Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, Massachusetts [29] Daryl R Gress, MD, FAAN, FCCM Professor of Neurocritical Care and Stroke; Professor of Neurology, University of California, San Francisco, San Francisco, California [35] Richard W Light, MD Professor of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University, Nashville, Tennessee [21] Rasim Gucalp, MD Professor of Clinical Medicine, Albert Einstein College of Medicine; Associate Chairman for Educational Programs, Department of Oncology; Director, Hematology/Oncology Fellowship, Montefiore Medical Center, Bronx, New York [43] Kathleen D Liu, MD, PhD, MAS Assistant Professor, Divisions of Nephrology and Critical Care Medicine, Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco, California [36] Jesse B Hall, MD, FCCP Professor of Medicine, Anesthesia and Critical Care; Chief, Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, Illinois [25] Joseph Loscalzo, MD, PhD Hersey Professor of the Theory and Practice of Medicine, Harvard Medical School; Chairman, Department of Medicine; Physician-in-Chief, Brigham and Women’s Hospital, Boston, Massachusetts [4, 33] Anna R Hemnes Assistant Professor, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee [Review and Self-Assessment] Ronald V Maier, MD Jane and Donald D Trunkey Professor and Vice-Chair, Surgery, University of Washington; Surgeon-in-Chief, Harborview Medical Center, Seattle, Washington [27] J Claude Hemphill, III, MD, MAS Professor of Clinical Neurology and Neurological Surgery, Department of Neurology, University of California, San Francisco; Director of Neurocritical Care, San Francisco General Hospital, San Francisco, California [35] Lionel A Mandell, MD, FRCP(C), FRCP(LOND) Professor of Medicine, McMaster University, Hamilton, Ontario, Canada [11] Katherine A High, MD Investigator, Howard Hughes Medical Institute; William H Bennett Professor of Pediatrics, University of Pennsylvania School of Medicine; Director, Center for Cellular and Molecular Therapeutics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania [39] Judith S Hochman, MD Harold Snyder Family Professor of Cardiology; Clinical Chief, Leon Charney Division of Cardiology; Co-Director, NYU-HHC Clinical and Translational Science Institute; Director, Cardiovascular Clinical Research Center, New York University School of Medicine, New York, New York [30] Gary W Hunninghake, MD Professor, Division of Pulmonary and Critical Care Medicine, University of Iowa, Iowa City, Iowa [9] David H Ingbar, MD Professor of Medicine, Pediatrics, and Physiology; Director, Pulmonary Allergy, Critical Care and Sleep Division, University of Minnesota School of Medicine, Minneapolis, Minnesota [30] John F McConville, MD Assistant Professor of Medicine, University of Chicago, Chicago, Illinois [22] David B Mount, MD, FRCPC Assistant Professor of Medicine, Harvard Medical School, Renal Division, VA Boston Healthcare System; Brigham and Women’s Hospital, Boston, Massachusetts [37] Robert S Munford, MD Bethesda, Maryland [28] Robert J Myerburg, MD Professor, Departments of Medicine and Physiology, Division of Cardiology; AHA Chair in Cardiovascular Research, University of Miami Miller School of Medicine, Miami, Florida [312] Edward T Naureckas, MD Associate Professor of Medicine, Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, Illinois [5] Richard J O’Brien, MD Head, Product Evaluation and Demonstration, Foundation for Innovative and New Diagnostics (FIND), Geneva, Switzerland [12] Talmadge E King, Jr., MD Julius R Krevans Distinguished Professor in Internal Medicine; Chair, Department of Medicine, University of California, San Francisco, San Francisco, California [19] Michael A Pesce, PhD Professor Emeritus of Pathology and Cell Biology, Columbia University College of Physicians and Surgeons; Columbia University Medical Center, New York, New York [Appendix] Alexander Kratz, MD, PhD, MPH Associate Professor of Pathology and Cell Biology, Columbia University College of Physicians and Surgeons; Director, Core Laboratory, Columbia University Medical Center, New York, New York [Appendix] Ronald E Polk, PharmD Professor of Pharmacy and Medicine; Chairman, Department of Pharmacy, School of Pharmacy, Virginia Commonwealth University/ Medical College of Virginia Campus, Richmond, Virginia [40] John P Kress, MD Associate Professor of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, Illinois [25] Mario C Raviglione, MD Director, Stop TB Department, World Health Organization, Geneva, Switzerland [12] Contributors John J Reilly, Jr., MD Executive Vice Chairman; Department of Medicine; Professor of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania [7, 18] Allan H Ropper, MD Professor of Neurology, Harvard Medical School; Executive Vice Chair of Neurology, Raymond D Adams Distinguished Clinician, Brigham and Women’s Hospital, Boston, Massachusetts [34] Richard M Schwartzstein, MD Ellen and Melvin Gordon Professor of Medicine and Medical Education; Associate Chief, Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts [1] Steven D Shapiro, MD Jack D Myers Professor and Chair, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania [18] Edwin K Silverman, MD, PhD Associate Professor of Medicine, Harvard Medical School; Channing Laboratory, Pulmonary and Critical Care Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts [18] Wade S Smith, MD, PhD Professor of Neurology, Daryl R Gress Endowed Chair of Neurocritical Care and Stroke; Director, University of California, San Francisco Neurovascular Service, San Francisco, San Francisco, California [35] A George Smulian, MBBCh Associate Professor of Medicine, University of Cincinnati College of Medicine; Chief, Infectious Disease Section, Cincinnati VA Medical Center, Cincinnati, Ohio [15] ix Julian Solway, MD Walter L Palmer Distinguished Service Professor of Medicine and Pediatrics; Associate Dean for Translational Medicine, Biological Sciences Division; Vice Chair for Research, Department of Medicine; Chair, Committee on Molecular Medicine, University of Chicago, Chicago, Illinois [5, 22] Frank E Speizer, MD E H Kass Distinguished Professor of Medicine, Channing Laboratory, Harvard Medical School; Professor of Environmental Science, Harvard School of Public Health, Boston, Massachusetts [10] Elbert P Trulock, MD Rosemary and I Jerome Flance Professor in Pulmonary Medicine, Washington University School of Medicine, St Louis, Missouri [24] Peter D Walzer, MD, MSc Professor of Medicine, University of Cincinnati College of Medicine; Associate Chief of Staff for Research, Cincinnati VA Medical Center, Cincinnati, Ohio [15] Charles M Wiener, MD Dean/CEO Perdana University Graduate School of Medicine, Selangor, Malaysia; Professor of Medicine and Physiology, Johns Hopkins University School of Medicine, Baltimore, Maryland [Review and Self-Assessment] Richard Wunderink, MD Professor of Medicine, Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, Illinois [11] 260 collapsed alveoli and improve oxygenation, although there are no conclusive data showing that IRV improves outcomes in clinical trials Continuous positive airway pressure (CPAP) This is not a true support mode of ventilation because all ventilation occurs through the patient’s spontaneous efforts The ventilator provides fresh gas to the breathing circuit with each inspiration and sets the circuit to a constant, operator-specified pressure CPAP is used to assess extubation potential in patients who have been effectively weaned and require little ventilator support and patients with intact respiratory system function who require an endotracheal tube for airway protection of assistance to match the patient’s effort have been developed Proportional assist ventilation (PAV) and neurally adjusted ventilatory assist ventilation (NAV) are two modes that are designed to deliver assisted breaths through algorithms incorporating not only pressure, volume, and time but also overall respiratory resistance and compliance in the case of PAV and neural activation of the diaphragm in the case of NAV Although these modes result in better patientventilator synchrony, their practical use in the everyday management of patients on MV needs further study Protective Ventilatory Strategy Section III Nonconventional Ventilatory Strategies General Approach to the Critically Ill Patient Several nonconventional ventilator strategies have been evaluated for their ability to improve oxygenation and reduce mortality rates in patients with advanced hypoxemic respiratory failure These strategies include highfrequency oscillatory ventilation (HFOV), airway pressure release ventilation (APRV), extracorporeal membrane oxygenation (BCMO), and partial liquid ventilation (PLV) using perfluorocarbons Although case reports and small uncontrolled cohort studies have shown benefit, randomized controlled trials have failed to demonstrate consistent improvements in outcome with any of these strategies Currently, these approaches should be considered “salvage” techniques and considered for patients with hypoxemia refractory to conventional therapy Prone positioning of patients with refractory hypoxemia has been explored because in theory it would tend to improve ventilation-perfusion matching Although this is conceptually appealing and simple to implement, several randomized trial in patients with acute lung injury did not demonstrate a survival advantage with prone positioning despite demonstration of a transient physiologic benefit The administration of nitric oxide (NO) gas, which has bronchodilator and pulmonary vasodilator effects when delivered through the airways and has been shown to improve arterial oxygenation in many patients with advanced hypoxemic respiratory failure, also failed to improve outcomes in patients with advanced hypoxemic respiratory failure Newer, promising strategies are intended to improve patient-ventilator synchrony, a major practical problem during MV Currently, the more advanced new ventilators allow patients to trigger the ventilator with their own effort while also incorporating flow algorithms that allow termination of cycles once certain preset criteria are reached; this approach has greatly improved patient-ventilator synchrony and comfort More recently, new modes of ventilation that synchronize not only the timing but also the levels Whichever mode of MV is used, in acute respiratory failure the evidence from several important controlled trials indicates that the use of a protective ventilation approach guided by the principles outlined later and summarized in Fig 26-1 is safe and offers the best chance of a good outcome: Set a target tidal volume close to mL/kg of ideal body weight Prevent plateau pressure (static pressure in the airway at the end of inspiration) over 30 cmH2O Use the lowest possible fraction of inspired oxygen (Fio2) to keep Sao2 ≥90% Adjust the PEEP to maintain alveolar patency while preventing overdistention and closure/reopening With the application of these techniques, the mortality rate among patients with acute hypoxemic respiratory failure has decreased to ∼30% from close to 50% a decade ago Patient Management Once the patient has been stabilized with respect to gas exchange, definitive therapy for the underlying process responsible for respiratory failure is initiated Subsequent modifications in ventilator therapy must be provided in parallel with changes in the patient’s clinical status As improvement in respiratory function is noted, the first priority is to reduce the level of mechanical ventilator support Patients on full ventilator support should be monitored frequently with the goal of switching to a mode that allows for weaning as soon as possible Protocols and guidelines that can be applied by paramedical personnel when physicians are not readily available have proved to be of value in shortening ventilator and intensive care unit (ICU) time, with very good outcomes Patients whose condition continues to deteriorate after ventilator support is initiated may require increased O2, PEEP, or one of the alternative modes of ventilation General Support during Ventilation Endotracheal intubation and mechanical ventilation have direct and indirect effects on the lung and upper airways, the cardiovascular system, and the gastrointestinal system Pulmonary complications include barotrauma, nosocomial pneumonia, oxygen toxicity, tracheal stenosis, and deconditioning of respiratory muscles Barotrauma and volutrauma overdistend and disrupt lung tissue; may be clinically manifest by interstitial emphysema, pneumomediastinum, subcutaneous emphysema, or pneumothorax; and can result in the liberation of cytokines from overdistended tissues, further promoting tissue injury Clinically significant pneumothorax requires tube thoracostomy Intubated patients are at high risk for ventilator-associated pneumonia (VAP) as a result of aspiration from the upper It is important to consider discontinuation of mechanical ventilation once the underlying respiratory disease begins to reverse Although the predictive capacities of multiple clinical and physiologic variables have been explored, the consensus from a weaning task force includes the following recommendations: (1) lung injury is stable/resolving, (2) gas exchange is adequate with low PEEP/Fio2 (15 Consider cardiac dysfunction or tamponade • ECHO • Treat appropriately Insert PAC VS unstable or acidosis worsens CI 30 CI